Improving Antibiotic Prescribing for Acute Respiratory Illnesses

Practice Problem: Unwarranted antibiotic prescribing practices when treating acute respiratory illnesses contribute to the national health threat of antibiotic resistance. PICOT: In a pediatric outpatient setting for patients ages 6-25 who have no documented uncontrolled comorbidities, presenting with an acute respiratory illness (P), does provider utilization of clinical guidelines, and patient and (caregivers) utilization of educational pamphlets, to collectively develop a plan of care (I), compared to providers and patients who do not utilize such strategies(C) result in a reduction in antibiotics prescribed for acute respiratory illnesses (O) in a 6-week timeframe (T)? Evidence: The evidence reviewed reported the utilization of clinical treatment guidelines accompanied with patient education, and the collaborative formation of the plan of care when treating acute respiratory illnesses, resulted in a modest or profound reduction in antibiotics prescribed. Intervention: Provider usage of The Centers for Disease Control (CDC) clinical guidelines accompanied by patient education to collaboratively formulate the treatment plan for the management of patients presenting with acute respiratory illnesses. Outcome: Antibiotic prescribing rates when managing acute respiratory illness declined from 82% baseline to 42% post-intervention. Conclusion: Provider utilization of CDC clinical guidelines, with patient education to collectively formulate a management plan when treating acute respiratory illnesses resulted in a reduction in non-medically indicated antibiotic prescriptive practices. IMPROVING ANTIBIOTIC PRESCRIBING 4 Improving Antibiotic Prescribing for Acute Respiratory Illnesses The Centers for Disease Control (CDC) identified that approximately 47 million unnecessary antibiotic prescriptions are written each year, which is estimated at 30% of all prescriptions given in an outpatient setting (CDC, 2013). These unwarranted prescription practices continue to be a great public health threat today (Sanchez et al., 2016). Although antibiotics are invaluable in eradicating many life-threatening bacterial infections, they become resistant and lose effectiveness primarily due to poor prescription practices (Srinivasan, 2017). The purpose of this project was to review evidence and use the findings to develop a proposed practice change. The proposed practice change promoted antibiotic stewardship as a mechanism to decrease unnecessary antibiotic prescriptions when treating acute respiratory illnesses in an outpatient setting. Significance of the Practice Problem In 2013, the CDC recognized antibiotic resistance as a major threat to the country’s health. According to the CDC (2020), antibiotic resistance remains a cause of death for over 35,000 people in the United States each year. Antibiotic resistance has also been associated with an estimated 2.8 million infections each year in the United States (CDC, 2020). The leading cause for these staggering numbers is the unnecessary prescribing of antibiotics when not medically indicated. The CDC has emphasized the need to combat antimicrobial resistance. Since an estimated, 60% of all U.S. antibiotic prescriptions are received in an outpatient setting (Guillford et al., 2016), the outpatient setting would be a good place to start a practice change project. In fact, it is estimated that in the outpatient setting, enough antibiotics are prescribed that 5 out of IMPROVING ANTIBIOTIC PRESCRIBING 5 every 6 person in the nation could receive a course of antibiotics each year. This equates to approximately 835 prescriptions per 1,000 people (CDC, 2019). Interestingly, in Scandinavian countries prescription rates are more than 50% lower (400 per 1,000), than the U.S. rate due to strict adherence to antibiotic stewardship practices (CDC, 2019). A program of Antibiotic Stewardship is promoted by the CDC as being a possible solution for the current antibiotic resistance crisis. Antibiotic stewardship is defined as concerted efforts used to improve antibiotic prescriptive practices by clinicians, so that antibiotics are only prescribed and used when indicated (Sanchez et al., 2016). A national quality measure, the Healthcare Effectiveness Data and Information Set (HEDIS) is a tool implemented to measure healthcare performance and utilized by many payers in the United States. Acute bronchitis, a diagnosis that is under the acute respiratory illness category, was added to the list of HEDIS in 2008. The goal set was not prescribing antibiotics for the treatment of acute bronchitis at a rate of 100%. When this performance rating was measured in 2018, the results indicated only 35% compliance (NCQA, 2020). Evaluation of the effectiveness of antibiotic stewardship within the outpatient settings could lead to practice changes capable of improving the future landscape of microbial resistance in the U.S.


Improving Antibiotic Prescribing for Acute Respiratory Illnesses
The Centers for Disease Control (CDC) identified that approximately 47 million unnecessary antibiotic prescriptions are written each year, which is estimated at 30% of all prescriptions given in an outpatient setting (CDC, 2013). These unwarranted prescription practices continue to be a great public health threat today (Sanchez et al., 2016). Although antibiotics are invaluable in eradicating many life-threatening bacterial infections, they become resistant and lose effectiveness primarily due to poor prescription practices (Srinivasan, 2017).
The purpose of this project was to review evidence and use the findings to develop a proposed practice change. The proposed practice change promoted antibiotic stewardship as a mechanism to decrease unnecessary antibiotic prescriptions when treating acute respiratory illnesses in an outpatient setting.

Significance of the Practice Problem
In 2013, the CDC recognized antibiotic resistance as a major threat to the country's health. According to the CDC (2020), antibiotic resistance remains a cause of death for over 35,000 people in the United States each year. Antibiotic resistance has also been associated with an estimated 2.8 million infections each year in the United States (CDC, 2020). The leading cause for these staggering numbers is the unnecessary prescribing of antibiotics when not medically indicated.
The CDC has emphasized the need to combat antimicrobial resistance. Since an estimated, 60% of all U.S. antibiotic prescriptions are received in an outpatient setting (Guillford et al., 2016), the outpatient setting would be a good place to start a practice change project. In fact, it is estimated that in the outpatient setting, enough antibiotics are prescribed that 5 out of every 6 th person in the nation could receive a course of antibiotics each year. This equates to approximately 835 prescriptions per 1,000 people (CDC, 2019). Interestingly, in Scandinavian countries prescription rates are more than 50% lower (400 per 1,000), than the U.S. rate due to strict adherence to antibiotic stewardship practices (CDC, 2019).
A program of Antibiotic Stewardship is promoted by the CDC as being a possible solution for the current antibiotic resistance crisis. Antibiotic stewardship is defined as concerted efforts used to improve antibiotic prescriptive practices by clinicians, so that antibiotics are only prescribed and used when indicated (Sanchez et al., 2016).
A national quality measure, the Healthcare Effectiveness Data and Information Set (HEDIS) is a tool implemented to measure healthcare performance and utilized by many payers in the United States. Acute bronchitis, a diagnosis that is under the acute respiratory illness category, was added to the list of HEDIS in 2008. The goal set was not prescribing antibiotics for the treatment of acute bronchitis at a rate of 100%. When this performance rating was measured in 2018, the results indicated only 35% compliance (NCQA, 2020). Evaluation of the effectiveness of antibiotic stewardship within the outpatient settings could lead to practice changes capable of improving the future landscape of microbial resistance in the U.S.

PICOT Question
In a pediatric outpatient setting for patients ages 6-25 who have no documented uncontrolled comorbidities, presenting with an acute respiratory illness (P), does provider utilization of clinical guidelines, and patient(caregiver) utilization of educational pamphlets, to collectively develop a plan of care (I), compared to providers and patients who do not utilize such strategies(C) result in a reduction in antibiotics prescribed for acute respiratory illnesses (O) in a 6-week timeframe (T)?

Population
The population consisted of clinic providers and all patients and caregivers ages 6-25 who presented to a pediatric outpatient setting with a chief complaint of an acute respiratory illness without a history of uncontrolled comorbidities.

Intervention
Clinical providers received pre-intervention surveys to evaluate their current attitude and beliefs about antibiotic stewardship and the use of clinical guidelines. Clinical providers then were trained on current evidence based clinical guidelines for the treatment of acute respiratory illnesses (Appendix A). Patient's and or caregivers of minors received the CDC sponsored pamphlet at registration that addresses the appropriateness of antibiotic use when treating acute respiratory illnesses, to review prior to seeing the provider (Appendix B). Posters were posted in each waiting and exam room that highlighted national clinical pathway guidelines when treating acute respiratory illnesses (Appendix C). Following the clinical evaluations, providers, patients, and caregivers collectively referenced both pamphlet and poster to discuss and evaluate the clinical appropriateness for the utilization of antibiotics in managing the patient's current illness.
Evidence has shown when providers utilize clinical guidelines, and patients and caregivers receive educational material, the results have been mildly effective at decreasing unwarranted antibiotic prescribing (Guillford et al., 2016).

Comparison
Pre-intervention antibiotic prescribing rates were obtained by reviewing retrospective data. The retrospective data reviewed were of patients diagnosed with acute respiratory illness during the same timeframe (December-January) the year prior. A tally was used to identify how many antibiotics were prescribed for those patients diagnosed with acute respiratory illnesses.
These pre-intervention numbers were then compared to post intervention numbers utilizing the electronic medical record (EMR) to identify if the intervention resulted in a reduction in antibiotics prescribed for acute respiratory illnesses. The Upper Respiratory Tract Antibiotic Tracking Tool was utilized to assist with auditing the data collected from the EMR (Appendix D). Past studies have indicated when patients were given educational material on the appropriateness of antibiotics for the treatment of acute respiratory illnesses, there was a mild reduction in the number of patients insisting on antibiotics for treatment (O'Sullivan et al., 2016). Other past studies have shown, providers familiar with national clinical guidelines for the treatment of acute respiratory illnesses, had a better understanding of the ineffectiveness and risk of prescribing antibiotics when they were not indicated, which resulted in a reduction in antibiotic prescribing rates (Barlam et al., 2016). Pre-and post-test surveys were compared to evaluate if there was a change in provider's attitudes and beliefs regarding antibiotic stewardship initiatives (Appendix E).

Outcome
The interventions of clinical provider's utilization of national clinical guidelines for the treatment of acute respiratory illnesses, accompanied by patient educational brochures, and clinical pathway posters, were projected to result in an overall reduction of unwarranted antibiotics being prescribed for acute respiratory ailments. An additional benefit was the family/patient and the provider collectively reviewed the materials together and formulated a plan of care. If the post intervention rate of antibiotic prescriptions was lower than the preintervention prescribing rates, then the intervention was judged to result in a clinically significant reduction in unwarranted antibiotics prescribed when treating acute respiratory illnesses. The outcome was measured by utilizing the EMR to calculate the average antibiotics prescribed in a specific six-week timeframe (December-January) the year prior to intervention compared to the average rate of antibiotics prescribed in the equivalent six-week timeframe of the current year post initiation of the intervention.

Timing
Forty-two days after the initiation of the practice change was the estimated timeline to see a reduction in previous prescribing trends and demonstrated compliance with using the guidelines in practice. Six weeks was considered a reasonable amount of time to see changes in prescribing trends, as it allowed adequate time for providers to adjust to the incorporation and utilization of the clinical guideline, patient education, and the new procedure of collectively discussing clinical findings and corroborating a plan of care with the patient.

Framework and Change Theory
One major focus for those working in the health care industry is the improvement and protection of the populations health (Meeker et al., 2016). Providers working in pediatric outpatient settings assisted with the fight against microbial resistance through utilizing clinical guidelines and educational material to collaboratively formulate an appropriate plan of care when treating acute respiratory illnesses. Educating patients/caregiver regarding the risk and misuse of antibiotics helped them take an active role in avoiding antibiotics when not indicated, which helped to decrease the risks of antimicrobial resistance in our healthcare system. Healthcare providers are an important source of influence when it comes to understanding and adapting health promoting behaviors. Utilizing clinical guidelines and patient education to collaboratively formulate a plan of care were key elements to assist in the avoidance of antibiotic resistance.

Framework
The framework that was used to implement this practice change was the Iowa Model of Evidence-Based Practice. The Iowa Model of Evidence-Based Practice was chosen as the framework because it is known for its strong theoretical model that aids in implementing evidence-based change. The multi-step process of the Iowa Model ensured changes achieve quality outcomes as well as sustainability (White & Spruce, 2015).
The Iowa model has various steps that helped to guide the process: 1. Identify a problem-antibiotic stewardship was identified as a national, agency, and accrediting body issue.
2. Form a team-the team consisted of the project leader, clinical leader, and medical director.
3. Assemble evidence-a comprehensive literature review was conducted.
4. Critique evidence-a synthesis of evidence was completed, and each article graded.

Set forth evidence-based practice recommendations-practice recommendations were
identified based on literature review.
6. Identify if findings support practice change-evidence was presented to the clinical leader for proposed practice change.
7. Develop practice change-a evidence-based practice change initiative was developed to address unwarranted antibiotic prescribing. Next pre-intervention antibiotic prescribing rates were evaluated and then the practice change was implemented.
8. Evaluate if practice change occurred-Post-intervention antibiotic prescribing rates were evaluated. 9. Evaluate structure process and outcomes-Process and outcomes were evaluated and modified. Feedback was then elicited to identify barriers. Necessary adjustments were made to ensure organizational sustainability.

Disseminate findings-
The results of the change project were then shared with staff and stakeholders.

Change Theory
Change is a necessary part of growth. Strategies and processes are continually evaluated and modified to maintain optimal growth. To assist with this practice change, Lewin's change theory was deployed. This change theory has been known to help support and sustain high quality outcomes in a multitude of professional settings (Wojciechowski et al., 2016). Lewin's change theory follows three stages: frozen, unfreeze, and refreeze. These three stages include identifying the current practice, pinpointing what can be changed about the current practice, and then implementing change that will result in a new way of performing the practice (Hussain et al., 2016).
The utilization of this change theory was achieved by evaluating the current practice trends when it came to antibiotic prescribing for acute respiratory illnesses, which represented the frozen stage. Next, the practice was unfrozen by sharing with providers the current health concerns surrounding antibiotic resistance related to the management of acute respiratory illnesses. Current evidence-based literature was shared with providers to assist in this process.
Providers were informed of current national initiatives that were going to be implemented as well as of similar expectations endorsed by accreditors and payors. Through the above discussions, providers were able to identify the magnitude of this current issue. Providers then had a better understanding of the need to relinquish current treatment practices when managing upper respiratory tract infections. In exchange, providers began to utilize nationally recognized evidence-based clinical guidelines and patient education material. The providers' actions represented the refreeze method of this change theory. Through collaborative efforts implemented by the student project leader that were supported by the clinical leader and medical director, all providers were able to identify the current practice problem and recognize the need for the practice change.

Evidence Search Strategy
To obtain a better understanding of the available evidence of antibiotic stewardship in outpatient settings, a literature review was conducted. The question used to guide the literature review was as follow: In a pediatric outpatient setting for patients ages 6-25 who have no documented uncontrolled comorbidities, presenting with an acute respiratory illness (P), does provider utilization of clinical guidelines, and patient (caregiver) utilization of educational pamphlets, to collectively develop a plan of care (I), compared to providers and patients who do not utilize such strategies(C) result in a reduction in antibiotics prescribed for acute respiratory illnesses (O) in a 6 week timeframe (T)?
An electronic search was conducted using the University of St. Augustine library portal and Google Scholar. Keyword search was performed using the following: antibiotic stewardship, improved antibiotic prescribing, antibiotic misuse, outpatient, ambulatory, education, outcomes, upper respiratory illnesses, cough, cold, bronchitis. Using a filter of publish dates between 2013present, well over 1,000 articles were returned, from the Academic Onefile, CINAHL complete, Info Trac Health Reference Center Academic, General Onefile and eBook index databases.
Articles addressing in-patient treatments were excluded from search, as well as microbial specific articles, and articles utilizing laboratory data. Peer reviewed Journals that were researched based were used as specified search criteria. Final narrowing was completed by limiting the search to include "antibiotics usage". At this point just under 100 articles were returned. The titles of the articles were reviewed for PICOT relevance. All potential articles identified at this point were further reviewed by exploring the abstracts and identifying articles that are suitable contenders in addressing the affect the practicing of antibiotic stewardship has on the overall reduction in antibiotic prescription ordering within an outpatient setting. Further reduction was made limiting articles to Academic Journal articles that were full text only. The remaining articles were eliminated based on the following non-PICOT relations: pharmacist driven studies, research that utilized diagnostic testing, identifications of specific microorganisms as a focus of study, and finally articles that focused on cost relations. This screening process resulted in 11 articles that directly addressed the focus of the intended PICOT question (see Figure 1-PRISMA for summary of results).
A total of 11 articles were retained and utilized to assist with the proposal development.
An evidence level and quality grade were assigned to each article by utilizing the John Hopkins Evidence-Based Practice, Evidence and Quality Guide (see Appendix F). Level I is a study conducted from a fully experimental approach. Level II is a study conducted utilizing a mixed experimental approach, and level III is a study conducted from a nonexperimental approach.
Quality ratings are graded A-C. A quality rating of an A identifies studies that show consistent reliable results. A quality rating of a B identifies studies that show consistent results, and a quality rating of a C identifies studies that have inconsistent results. The evidence level is ranked I-III and the quality scored a B rating (see Table 1).
The articles retained were a grade level 2 with a couple articles being 1 and 3's. The quality of all the articles were a quality level of a B with one single article being a quality level A. The design of these articles included clustered randomized, quasi experimental, and linear mixed effect. Out of the 11 articles retained, most articles were quantitative except for one article that was a qualitative study and another article a systematic review.

Themes from the Evidence
All articles that were reviewed had a similar outcome when it came to the utilization of guidelines and education to reduce antibiotics prescribed for acute respiratory illnesses. In each article the study outcomes had either a modest or profound effect in reducing antibiotics prescribed for acute respiratory illnesses. A synthesis of articles reviewed was conducted to identify similarities in other individual articles that helped to support the PICOT of this paper (see Figure #2). Emerging themes were identified that consistently had positive outcomes and consisted of the following interventions: clinical guidelines, provider education, regular provider feedback, and patient education.

Clinical Guidelines
The studies reviewed showed, utilization of clinical guidelines results in a significant reduction in antibiotics prescribed. Clinical guidelines assist providers to formulate treatment plans that are evidence-based and scientifically proven to be the most advantageous approach when treating specific ailments. Providers who have clinical guidelines to reference when treating patients have the benefit of being able to reference the most appropriate treatment plans for their patients. Utilizing clinical guidelines helps to decrease the prescribing of antibiotics when not clinically indicated. The implementation of clinical guidelines resulted in a 95% compliance rate when it came to the utilization of clinical guidelines to assist in the reduction of antibiotic prescribing (Frisina, 2016). Gifford (2017) noted there are no significant outcome differences when giving guidelines in paper form or embedded into the EMR. The key to change is simply providing providers with clinical guidelines.

Provider Education
According to Holstiege et al. (2015), education is key to achieve adherence to the appropriate utilization of clinical guidelines. Presenting educational material to providers in a multifaceted approach results in improved outcomes (Holstiege et al., 2015). A multifaceted approach helps to encompass the varying learning styles that each individual provider may have.
When emphasis is placed on educating the provider through the utilization of guidelines, a vast reduction of antibiotic prescribing is achieved. Providers who have ongoing regular educational sessions, result in higher guideline adherence when treating acute respiratory illnesses (Clegg, 2019). In comparison, when educational sessions are less frequent there is a decrease in guideline adherence resulting in an increase in antibiotics prescribed when not clinically indicated.
Educational sessions are important to assist providers with clinical guideline utilization.

Provider Feedback
The incorporation of provider feedback is an intervention noted to have a positive impact in supporting the reduction of antibiotic prescribing when not indicated for acute respiratory illnesses. Holstiege et al. (2015), emphasized the idea that in addition to the utilization of clinical guidelines accompanied by provider and patient education, providers who have regular feedback regarding their antimicrobial stewardship efforts tend to be more successful at not prescribing antibiotics for acute respiratory illnesses. The key to maintaining adherence to clinical change and utilization of clinical guidelines is to provide providers with feedback on a regular basis (Clegg, 2019).

Patient Education
Patients are consumers of their health care. To achieve desired positive health outcomes, patients as well as providers must enter into a collaborative management of care agreement. This collaboration is best achieved when the patient has some sort of background knowledge regarding the treatment approach to the acute ailments. When targeting both providers and patients a vast reduction in antibiotic prescribing can be achieved as both provider and patient are familiar with the appropriate antibiotic prescribing practices surrounding acute respiratory illnesses. Targeting both groups is most impactful at achieving the desired outcome versus targeting either group alone (Wei et al., 2017).
Synthesis of the articles resulted in the identification of several key components that are pivotal in supporting the PICOT discussed in this paper. Clinical guidelines were highlighted as being one of the key major ingredients necessary to achieve the PICOT goal of antibiotic reduction. Clinical guidelines are like the roadmap to guiding this practice change. To accompany the clinical guidelines is the educational component, which requires the education of both the provider as well as patient to achieve the desired outcome. Provider feedback was also identified as being advantageous.

Practice Recommendations
There were 11 articles that were reviewed seeking evidence to support the PICOT question. The evidence supported providers use of guidelines and patient education to reduce antibiotic prescriptions for diagnosed acute respiratory illnesses. The practice recommendation was to implement the utilization of national clinical guidelines, and supplement this with patient education pamphlets as well as posters, and collaborative patient/provider plan of care development to improve nonessential antibiotic prescribing for the management of acute respiratory illnesses. This is compared to providers who did not refer to national clinical guidelines to assist in formulating the treatment plan of care for the management of acute respiratory illness and patients who did not receive any educational material (see Appendix G).
The evidence reported in the literature supports, the combination of clinical providers utilizing clinical guidelines accompanied by patients receiving educational information regarding how to manage acute respiratory illnesses resulted in a reduction in antibiotics being prescribed.
Variation was noted in the literature when it came to how significant the reduction of antibiotic prescribing was when evaluated over time. For example, in the study conducted by Gifford et al., (2017), that was conducted over 3.5 years resulted in higher reductions in antibiotics prescribed compared to the study conducted by Meeker et al., (2016), that utilized a 1-year intervention period. In reviewing these two studies it appears that the longer the intervention is in place continued reductions in unnecessary antibiotic prescribing occurs. To sustain this practice change, an annual review mechanism should be implemented after the project to provide feedback to providers on antibiotic prescribing practices.
As payors are increasingly looking for ways to identify quality measures to improve quality of care, regulations, as well as ways to reimburse for the quality of health services rendered (Adirim et al., 2017), organizations and providers must identify, develop, and implement ways to improve quality of care. If providers want to provide the best care for patients and subsequently be reimbursed, the institution needs a strong focus on achieving national quality measures such as HEDIS scores/measurements. HEDIS is used by well over 90% of health plans to measure performance on important dimensions of care and reimbursement for services (NCQA, 2020). Institutions need to meet the new antimicrobial stewardship requirements as stipulated by the Center for Medicare & Medicaid Services (CMS) to maximize reimbursement, as well as the Joint Commission if they want to maintain their accreditation (Joint Commission, 2019). Sound antibiotic prescribing is one of the national quality measures in the forefront of payor's reimbursement qualifiers at this time, and this PICOT question helps to not only reduce antimicrobial resistance but also assists providers in maximizing reimbursement for services rendered.

Project Setting
The setting in which the change project took place was within a pediatric outpatient clinic in the Chicagoland area. This pediatric clinic sees approximately 65 patients a day. The pediatric clinic is affiliated with a major medical center and is known for consistently providing quality patient care.

Participant Criteria
Eligible participants included the 5 providers who practice at the clinic and all patients and caregivers of minors, within the age range of 6-25 and have no history of uncontrolled comorbidities. Patients with uncontrolled comorbidities or who have recently been evaluated and treated in the last 30 days for any ailments were excluded from participation. The patients who fell within the appropriate age category and were otherwise healthy were chosen as participants. Finally, these participants were also required to present to the clinic for guidance and management of symptoms suggestive of an acute upper respiratory illness to be an included participant. All potential participants had to have illness that was otherwise self-limiting, with a low probability for the need of a higher level of care which was confirmed by all exam findings being otherwise normal. All participants had to be able to return home after they were seen and evaluated.

Mission and Vision
The pediatric clinic is committed to providing high quality, patient-focused care that is also cost effective. The clinic's mission and vision consist of maintaining a commitment to quality patient care to achieve and maintain superior quality patient outcomes.

Need
Organizational need was established by evaluating national goals and trends in healthcare and then identifying areas within the pediatric clinic that could benefit from change that was consistent with these national goals and benchmarks. An evaluation of the current antibiotic stewardship initiatives was completed. This clinic had no formal antimicrobial stewardship efforts in place.
In September of 2014, President Barack Obama signed an executive order requiring healthcare facilities to implement concerted efforts to combat antimicrobial resistance (CDC, 2015). The Center for Medicare and Medicaid Services (CMS) required all outpatient facilities of any size (from single to multiple providers) to implement an antibiotic stewardship initiative (CDC, 2015).
The clinical lead and medical director identified the need to meet the CMS requirement of implementing antibiotic stewardship initiatives in efforts to improve antimicrobial stewardship. However, nothing had been formally implemented. Leaders were therefore approached regarding the positive outcomes this change project could achieve. Specifically, the implementation of the evidenced-based changes that were highly likely to assist the pediatric outpatient clinic in meeting national benchmark and goals, as well as maintaining accreditation.
After the executive leaders met and agreed, tentative plans were made to assist with the implementation of the proposed changed project.

Stakeholders
A single clinical leader was assigned to oversee the project. Major stakeholders consisted of a clinical leader, medical director, the medical providers, clinic staff, patients, and caregivers.
After the clinical leader reviewed the change project proposal and discussed it with the medical director, a plan was developed to elicit buy in from the providers.
To assist with the planning phase of this change project a SWOT analysis was completed.
The SWOT analysis provided a comprehensive overview of the potential strengths, weaknesses, opportunities as well as threats for implementation of the change project (see Appendix I).

Strengths
The SWOT analysis identified many helpful strengths. They consisted of clinical leader buy in, the ease of implementation of the change project, little demand for outside resources to accomplish the practice change, and the strong desire by all involved to achieve national benchmarks.

Weaknesses
Several potential weaknesses were identified. First, a decrease in patients' satisfaction could result when the desired treatment of choice, an antibiotic, is not ordered. There was potential for medical providers to resist using clinical guideline to guide their medical decision making. Lastly, the increased time spent educating each provider and patient could result in a disruption in typical workflow.

Opportunities
The change project provided an opportunity to consistently emphasize to clinical providers the benefits of clinical guidelines for all associated treatment modalities. An additional bonus was providing the providers educational sessions on how to have confident conversation with patients if they encountered pushback about this practice change. Another opportunity was the collaboration between the provider and patient/caregiver to develop the treatment plan of care.

Threats
One identified threat was the ability to obtain an adequate amount of the "Be Smart" pamphlets that were created and released by the CDC. These pamphlets educate patients about appropriate antibiotic use and were utilized as educational tools for patients during the acute visits. This threat was mitigated by printing pamphlets as allowed by the CDC. Other potential threats were patients/caregiver reading ability and or refusal to review the educational material prior to seeing the provider. Assistance was provided by clinical staff to any patient who reports the inability to read.

Project Overview
The mission and vision of this change project was to decrease the future risk of antimicrobial resistance through the utilization of clinical guidelines and education for clinical providers as well as patients to reduce inappropriate antibiotic prescribing. The project setting consisted of a pediatric outpatient clinic that regularly manages minor acute self-limiting ailments such as upper respiratory tract infections.

Mission
The project mission was consistent with the overall organization's mission. Both the clinic and the project leader wanted to improve health outcomes of the community through the utilization of education and clinical change that is evidenced based.

Goal
The short-term goals of this project include the provider's consistent use of the guidelines, improved provider's perception of the value of antibiotic stewardship, and a reduction in antibiotics prescribed for acute respiratory illnesses by 10% in the six-week timeframe post interventions as compared to pre-intervention data. The long-term goal aims to be reduction in antibiotic prescribed for acute respiratory illnesses by at least 15%, compared to preintervention; thereby, contribute to the desired resolution of antibiotic resistance. The targeted goal of a reduction of at least 15% is consistent with the suggested national outpatient benchmark goal as established by the national action plan for combating antibiotic resistance, for all outpatient facilities (The White House, 2015).

Risks
One potential risk consisted of providers being placed under extreme pressure by dissatisfied patients. Often patients perceive the need for an antibiotic with any respiratory infection and become upset when the clinical visit does not result in an antibiotic being prescribed. Another potential risk consisted of providers not consistently utilizing the clinical guidelines when formulating the patient's plans of care. If it was found a provider was not utilizing the clinical guidelines as demonstrated by high individual provider prescribing rates, the medical director reinforced guideline adherence through one-on-one audit and feedback.
Another risk included patients not receiving an antibiotic when needed or when symptoms changed. Patients were strongly encouraged to seek follow up care for any worsening of symptoms so they could be re-evaluated.

Project Plan (Method)
The creation of the project planning schedule was guided by the IOWA model evidencebased framework. Each step in the project proposal was governed by the steps within the IOWA model to ensure evidence-based practice improvements were achieved. The plans for implementation of this change project are outlined in the table Appendix J.
The project began with this DNP student meeting with the preceptor, who was also the clinical leader. To accomplish the initial step of the IOWA model the project problem was identified, and the topic was shared with the clinical leader and an assessment of the current clinical efforts regarding antibiotic stewardship was ascertained. In the next step of the IOWA model the DNP student, who was also the project leader met with the formed team who consisted of the clinical leader and medical director who reviewed the proposed plan and recommendations. The following steps of the IOWA model of assembling evidence and critiquing the evidence was accomplished by the project leader. The subsequent step of evidencebased practice recommendations was reviewed and shared and adjustments to the project plan were made as suggested by the medical director, and the clinical leader.
A review of the national clinical guidelines for the treatment of upper respiratory tract infections was conducted. The national clinical guidelines were identified, and a clinical order set was created that was used by the clinical providers, when treating upper respiratory tract infections. In accordance with the next step in the IOWA model the clinical guidelines were shared with the clinical lead, and medical director for review.
Once the project was approved by both the university and the clinic, a survey was administered to evaluate the clinical provider's current attitudes and beliefs regarding antibiotic stewardship. A retrospective review of the average rate of antibiotics prescribed for upper respiratory tract infections for the correlating 6-week intervention timeframe (December-January) from the year prior was conducted. This rate served as the pre-intervention comparison rate. Next an antibiotic stewardship presentation was prepared for providers sharing the preintervention rate of prescribing, followed by the introduction of the planned practice change.
This project implemented the clinical guideline and an associated order set, evaluated provider knowledge of and satisfaction with the practice change, and improved-the provider/patient decision making process by initiating the use of the CDC endorse antibiotic stewardship information and campaign materials. Small informational sessions were held to review the new antibiotic prescribing clinical guideline order sets to be used, as well as familiarizing providers with the patient CDC antibiotic "Be Smart" pamphlets and posters. Following the informational sessions, Q & A sessions were scheduled for those providers who wanted additional information/ resource prior to project implementation.
Clinical guideline order sets were made available at all workstations, as well as all educational material 1 week prior to the project go live date. The project went live for a total of 6-weeks and during this phase of the project implementation process the interventions were carried out with close monitoring of its process and outcomes. During this step the project leader closely monitored and ensured all steps of the change project were being carried out. The steps examined included the provider utilization of the clinical guidelines, patients receiving pamphlets, as well as provider and patient collectively developing a treatment plan of care.
Throughout the 6-week timeframe, the project leader checked in with the clinical leader to discuss any provider questions or concerns. During this time, the project and clinical leader reviewed data obtained to analyze if the project was moving toward the intended directional outcome as well as evaluated the untoward outcomes that were discovered along the way. Data was collected from the EMR weekly, tallying number of patients seen and diagnosed with acute respiratory illness and those prescribed antibiotics along with provider compliance with the guidelines. In addition, the project leader evaluated provider concerns and compared them to appraise the current rate of prescribing. Unforeseen issues and concerns were discussed with the clinical leader and medical director, at the end of week 2 and week 4. This step, which was the evaluate structure and process and outcomes phase of the IOWA model was an important phase as it gave the project and clinical leader the ability to refine planned activities based on the outcomes that were noted to ensure the project was being implemented to the best of its abilities.
The project leader used the EMR to collect interventional antibiotic prescribing rates each week throughout the interventional period. Bi-weekly tallies of current prescribing rates were shared by posting graphs in the staff room. The project implementation phase concluded after the intervention had been in place for 6-weeks.
The final rate of antibiotics prescribed during the implementation phase was calculated.
The post-interventional rate of antibiotics prescribed was compared to the pre-interventional rate.
Then, the project leader administered the post implementation survey to evaluate if there was a shift in attitudes and beliefs regarding antibiotic stewardship, as well as to identify strengths, weaknesses, and overall opinions of the change project. To achieve the final step in the IOWA model, the final project results were presented in a PowerPoint presentation at a staff meeting 30 days following the completion of the project.
The required resources for this EBP change project consisted of the utilization of the EMR that was already in place, the implementation of the national clinical guideline to treat acute upper respiratory illnesses, and the CDC "Be Smart" pamphlets and posters. A minimal budget was required to implement this project. Provider familiarization of the guidelines occurred during regularly scheduled staff meetings resulting in no additional cost to pay staff.
The primary source of cost was simply the paper and ink to print. There was a small increase in provider time spent educating patients surrounding appropriate antibiotic use; however, this was minimal and did not affect revenue. As CMS and other health plans and payers transforms its payment model from volume-based care models to quality-based payments, the implementation of this project helped to maximize potential payor reimbursement as HEDIS quality measures for appropriate prescribing were achieved. Achieving these evidence-based practice changes that improved patient focused outcomes far exceeded any potential minor increase in cost (Kliethermes, 2019).

Leadership Role
As the leader of this planned change project, this DNP student displayed the following qualities: good communication and organizational skills, the ability to multi-task, as well as flexibility when there was needed changes. The project leader oversaw all aspects of this change project from the planning phase, through the start and finish. Effective communication and collaboration with the key stakeholders were mandatory for success. Time was spent familiarizing staff with the clinical guidelines and its utilization, as well as familiarizing staff about the patient's pamphlet. A considerable amount of time was spent communicating with the clinical leader who was the access point into the pediatric clinic. The clinical leader was the main point of contact within the clinic, and facilitated contact with medical directors, medical providers, and staff. The project leader was responsible for implementing a timeline for activities to be completed, as well as overseeing tasks were being completed. Feedback from the team was regularly elicited to gain insight regarding how the project was progressing. The project leader was receptive to the information shared by other stakeholders and responsive to improve and/or rectify any issues that arose. These leadership qualities were crucial, to successfully carryout this change project.

Results
To evaluate the outcome of this planned change project, multiple steps were initiated.
Participants were selected based on diagnosis, age, and absence of co-morbidities. All participants selected had been seen, evaluated, and diagnosed with acute respiratory illness.
Participants had to be otherwise healthy with no uncontrolled comorbidities to be selected for participation. All patients and caregivers seen within the pediatric care setting received the educational intervention; however, only the patients meeting the above criteria were included as participants to be evaluated for the practice change.

Provider Survey
The provider survey was administered prior to the start of the intervention and at the conclusion of the intervention. Provider post-intervention surveys were compared to preintervention surveys seeking to identify any change in knowledge attitude or beliefs, about antibiotic stewardship. A copy of the provider survey can be found in Appendix E, accompanied by a modification permitted statement.

EMR Review
The EMR was utilized to review all patient visits, however, only the patients that met the above criteria were included as participants of the change project. Once participants who met the criteria were identified, a quantitative analysis was conducted to identify the number of patients who were prescribed antibiotics after the educational interventions were implemented. The number of antibiotics prescribed to patients was assessed and collected at weeks 2, 4, and 6. The number of participants diagnosed with an acute respiratory illness and the number of participants prescribed an antibiotic was the only outcome data collected from the EMR. Prior to the start of the practice change, retrospective data was collected to serve as the comparison group. A baseline retrospective evaluation was collected from the EMR. This retrospective data evaluation was conducted by identifying patients who were seen in the corresponding six-week timeframe (December-January) the year prior to intervention who also met the above criteria, and then calculating the rate of antibiotic prescribed prior to the initiation of the intervention. This information was earmarked as being the pre-intervention comparison group.

Data Collection
The antibiotic prescription data was collected from the EMR. The CDC (2019) recommends the use of electronical medical records as a means for collecting data to analyze prescribing trends. The student project leader who initiated the practice change collected the data from the EMR with the support and guidance of the clinical leader. Collection of data was performed for each individual provider. This allowed tracking of each individual provider's prescribing rates and guideline compliance. Once data was collected for each provider, it was tallied together to reflect the total prescribing habits of all the clinic providers. Any patient chart, that had missing data or did not achieve the three selection criterions were excluded as qualifiable participants for the practice change. The data collected was stored and collected only after the patient was deidentified to ensure privacy of the health information. This was fully achieved by not using patients' names and simply keeping a running tally of the quantity of patients seen as well as those who were prescribed antibiotics. Anonymity of provider names when evaluating individual prescribing rates was also maintained when collecting data by assigning each provider to a number 1-5. This information was then entered into an excel document and stored in the student project leader's laptop. This laptop was only accessible by coded entry access. After the collected data had been analyzed, the post intervention rate of prescribing had to be less than the rate of prescribing in the pre-intervention group in ordered for the project to be considered clinically significant. The provider pre-and post-intervention surveys were compared to evaluate for any change in provider attitudes and beliefs regarding antibiotic stewardship. Individual provider prescribing rates was not compared given the use of the CDC guidelines and materials were new to the clinic but will assist in providing information to help sustain the change in practice.

Interventional Assessments
Following project initiation, an assessment of the interventional changes was conducted every 2 weeks of the 6-week interventional timeframe. Please see Appendix J for list of scheduled activities. To consider the interventional outcomes as being clinically meaningful improvements, the interventional rate of antibiotics prescribed had to be less than the retrospective analysis number of the comparison group. The quantitative data was gathered and then the total number of antibiotics prescribed were calculated, for the pre and post intervention periods. During the preimplementation period of the project there was a total of three hundred ninety-eight (398) antibiotics prescribed, as compared to the post implementation were there was a total of ninety-three (93) antibiotics prescribed. Therefore, the utilization of clinical guidelines and education for clinical providers as well as patients to reduce inappropriate antibiotic prescribing was effective when treating acute respiratory illnesses based on these results (See Figure 2).
A paired t-test was used to compare pre-and post-antibiotics prescribed. As seen in Table   4, there was a statistically significant difference between the score of pre (M=13.27, SD=7.90) and post (M=3.10, SD=1.86) results. The t-value was 8.722, which was significant at alpha= 0.05, resulting in statistically significant differences between the results of pre-and post-antibiotics prescribed. The practice changes implemented, successfully decreased antibiotic prescribing for acute respiratory illness at this clinic.
The data produced from the provider pre-and post-implementation survey was ordinal.
Higher scores are associated with more favorable opinions. Post implementation provider surveys showed a more favorable opinion when it came to the value of antibiotic stewardship.
Individual provider prescribing rates were reported as a percentage, with a goal of <10%. Higher individual prescribing rates were associated with nonadherence to clinical guidelines. This EBP change project was reviewed and approved by the Evidence Based Practice review committee (EPRC) through the University of St. Augustine as well as the pediatric clinic's medical director prior to initiation. Human rights were protected throughout the practice change project and the data collected was de-identified. The change itself presented no potential harm to the patients.

Impact
The findings of this evidence-based practice change seeking to address the unwarranted antibiotic prescribing for acute respiratory illnesses in a pediatric setting, substantiated that the utilization of clinical practice guidelines and patient education can significantly reduce the number of inappropriate antibiotics being prescribed. Initially, providers in the pediatric setting were prescribing antibiotics at a rate of 82% when managing acute respiratory illness. After implementation of the 6-week evidence-based practice change, this rate decreased to 42%. These findings are consistent with those of past literature that reported the utilization of clinical guidelines, patient education, and collaborative formation of the plan of care, resulted in an overall reduction in antibiotics prescribed when managing acute respiratory illnesses.
To accomplish this clinical practice change, the providers in this pediatric clinical setting made a concerted effort to achieve best prescribing practice by utilizing national clinical guidelines for the management of acute respiratory illnesses. This student project leader believes the success of this project was in large due to the staunch support of the medical director who fostered encouragement and buy in from the providers. The medical director and provider support, coupled with patient education, manifested a new prescribing culture within this pediatric clinic. These improved prescribing practices enhanced outcomes for the patients, fulfilled federal and regulatory requirements, and improved reimbursement for services. Most importantly, these newly adopted practice changes will help to win the global battle to combat antimicrobial resistance. To support the continued success and sustainability of this practice change the clinic will incorporate antibiotic stewardship reviews, routine chart audits, provider feedback, and communications. These practices will highlight the clinic's overall commitment to antibiotic stewardship. Further, they will continue to gather data on individual provider prescribing rates, to evaluate national clinical guideline adherence.
This student project leader believes one of the greatest limitations experienced during this change project was the impact COVID-19 placed on the vast reduction in quantity of patients seen during the implementation phase as compared to the pre-implementation phase. The provider survey results indicated patients and caregivers commonly placed undue pressure on providers to prescribe antibiotics for viral ailments.
However, the lower patient volume meant providers could spend more time focusing on proper clinical guideline-based management, care, and education for each patient. It could be assumed that, without this lower patient volume, implementation of such clinical practice change could have resulted in increased stress for providers. With less time for education, the providers might have steered away from clinical guidelines and given in to patient demand. However, the individual provider prescribing monitoring and feedback suggested the actual final prescribing rate would have been only slightly higher if the pandemic had not been a factor.
The lower patient volume was advantageous in the sense that it allowed providers the opportunity to become familiar with this practice change, which, will help solidify the changes into a routine when moving forward. When patient volume returns closer to normal levels, providers will already have a strong grasp on this practice change, which will support its sustainability.

Plans for Dissemination
The results of the change project were shared with staff and stakeholders every two weeks throughout the project by posting graphs on the unit. The final project results were first shared with the clinical leader and medical director to discuss sustainability measures such as standard operating policy, and annual reviews on prescribing rates and individual provider prescribing performance. Next, project results were shared at a staff meeting 2 weeks after completion of this project. All providers and staff in the pediatric clinic were invited to attend the presentation.
The student project leader will also share the results of the change project via poster and PowerPoint presentations at the American Academy of Pediatrics virtual conference. Since antimicrobial resistance is a global problem, sharing the findings of this project can help to improve antimicrobial stewardship policies in the pediatric clinical settings worldwide. Prior to any professional submissions, abstracts, presentations, and manuscripts will be subjected to a minimum of 3 separate peer reviews.

Quality Grade # Articles Meeting This Criteria
A (high quality) 2 B (good quality) 10 C (low quality) -      • Management of the common cold, nonspecific URI, and acute cough illness should focus on symptomatic relief. Antibiotics should not be prescribed for these conditions. • There is potential for harm and no proven benefit from over-the-counter cough and cold medications in children < 6 years. These substances are among the top 20 substances leading to death in children <5 years. • Low-dose inhaled corticosteroids and oral prednisolone do not improve outcomes in children without asthma.

No theoretical framework
Overall reduction in antibiotic prescribing was noted in those utilizing policy guidelines.
Education alone does not assist in reducing antibiotic prescribing. Education with the addition of treatment policy guidelines helps to reduce overall antibiotic prescribing and also minimizes potential complications that can be associated with antibiotic use. The intervention consisted of patients/parents receiving education material about antibiotics either before or during patient visits and the control received no information.

No theoretical framework
The intervention groups showed a decrease in antibiotics prescribed when compared to the control group.
No major difference was noted if the educational material is given before or during the visit.
When educational material is given to patients/parents there is a reduction in the amount of antibiotics prescribed for acute respiratory illnesses when compared to not giving educational material. There was not much difference in the reduction of antibiotics prescribed when timing of sharing the educational material was before or during the patient visits.
Wei, X., Zhang, Z., Walley, J., Hicks, J., Zeng, J., Deng, S. ……., & Lin, M. Week 3 Week 5 Week 7 Week 9 Week 11 Week 13 Week 15 Week 1 Week 3 Week 5 Week 7 Week 9 Week 11 Week 13 Week 15 Week 1 Week 3 Week 5 Week 7 Week 9 Week 11 Week 13 Week 15 Create clinical smart set to be utilized when treating upper respiratory tract infections x Under the direction of clinical leader identify which clinic will take part in project change x Prepare antibiotic stewardship presentation for meeting for providers that will be participants of practice change Week 3 Week 5 Week 7 Week 9 Week 11 Week 13 Week 15 Week 1 Week 3 Week 5 Week 7 Week 9 Week 11 Week 13 Week 15 Week 1 Week 3 Week 5 Week 7 Week 9 Week 11 Week 13 Week 15 with the patient Be Smart pamphlets Hold Q & A sessions for those providers who are requesting additional information/ resource prior to project implementation.
x Deliver all educational material to the pediatric clinic Week 3 Week 5 Week 7 Week 9 Week 11 Week 13 Week 15 Week 1 Week 3 Week 5 Week 7 Week 9 Week 11 Week 13 Week 15 Week 1 Week 3 Week 5 Week 7 Week 9 Week 11 Week 13 Week 15 Week 3 Week 5 Week 7 Week 9 Week 11 Week 13 Week 15 Week 1 Week 3 Week 5 Week 7 Week 9 Week 11 Week 13 Week 15 Week 1 Week 3 Week 5 Week 7 Week 9 Week 11 Week 13 Week 15 Conduct final meeting presenting the outcome results of the practice change x Legend: x-denotes the timeframe an activity will be completed in